STATE OF ILLINOIS COUNTY OF ______________ Small Estate Affidavit I, _________________________________________(name of affiant), on oath state: 1. (a) My post office address is:________________________________________________ (b) My residence address is:_________________________________________________and (c) I understand that, if I am an out-of-state resident, I submit myself to the jurisdiction of Illinois courts for all matters related to the preparation and use of this affidavit. My agent for service of process in Illinois is: NAME_______________________________________ADDRESS________________________________ CITY________________________________________TELEPHONE______________________________ I understand that if no person is named above as my agent for service or, if for any reason, service on the named person cannot be effectuated, the Clerk of the Circuit Court of ______________(County)____________________ (Judicial Circuit) Illinois is recognized by Illinois law as my agent for service of process. 2. The decedent’s name is ___________________________________________________________ 3. The date of the decedent’s death was ________, and I have attached a copy of the death certificate hereto. 4. The decedent’s place of residence immediately before his death was ________________________ _______________________________________________________________________________ 5. No letters of office are now outstanding on the decedent’s estate and no petition for letters is contemplated or pending in Illinois or in any other jurisdiction, to my knowledge. 6. The gross value of the decedent’s entire personal estate including the value of all property passing to any party either by intestacy or under a will, does not exceed $100,000. and consists of the following: (Here list each asset, e.g. cash, stock and its fair market value). ______________________________________________________________________________ ______________________________________________________________________________ 7. Please mark (X) correct box. (a) All of the decedent’s funeral expenses have been paid, or (b) The amount of the decedent’s unpaid funeral expenses and the name and post office address of each person entitled thereto are as follows: Name______________________________________Post Office Address___________________________ ___________________________________________________________Amount____________________ 8. There is no known unpaid claimant or contested claim against the decedent, except as stated in paragraph 7. 9. (a) The names and places of residence of any surviving spouse, minor children and adult dependent * children of the decedent are as follows: Name and Relationship Place of Residence Age of Minor Child American LegalNet, Inc. www.FormsWorkflow.com *(Note: An adult dependent child is one who is unable to maintain himself and is likely to become a public charge.) (b) The award allowable to the surviving spouse of a decedent who was an Illinois resident is $_________ ($10,000, plus $5,000 multiplied by the number of children and adult dependent children who resided with the surviving spouse at the time of the decedent’s death. If any such child did not reside with the surviving spouse at the time of the decedent’s death, so indicate in 9(a). (c) If there is no surviving spouse, the award allowable to the minor children and adult dependent children of a decedent who was an Illinois resident is $______________ ($10,000, plus $5,000 multiplied by the number of minor children and adult dependent children), to be divided among them in equal shares. 10. (a) The decedent left no will. The names, places of residence and relationships of the decedent’s heirs, and the portion of the estate to which each heir is entitled under the law where decedent died intestate are as follows: Name, relationship and place of residence (b) Age of Minor Portion of Estate OR The decedent left a will, which has been filed with the clerk of an appropriate court. A certified copy of the will on file is attached. To the best of my knowledge and belief the will on file is the decedent’s last will and was signed by the decedent and the attesting witnesses as required by law and would be admittable to probate. The names and places of residence of the legatees and the portion of the estate, if any, which each legatee is entitled are as follows: Name, relationship and place of residence Age of Minor Portion of Estate [Indicate either 10(a) or 10(b)] (c) Affiant is unaware of any dispute or potential conflict as to the heirship or will of the decedent. 11. The property described in paragraph 6 of this affidavit should be distributed as follows: Name Specific Sum or Property to be distributed The foregoing statement is made under the penalties of perjury. (Note: A fraudulent statement made under the penalties of perjury is perjury, as defined in Section 32-2 of the Criminal Code of 1961.) _______________________________________ Signature of Affiant Date Daytime telephone_______________________ Signed and sworn to be ____________________________________________ Before me this _____________day of________________________,_________ __________________________________ Notary Public 12-13-05 American LegalNet, Inc. www.FormsWorkflow.com